An Online Structured Diabetes Self-Management Education and Support Programme Improves Glycaemic Control in Young Adults with Type 1 Diabetes

Figures & data

Table 1 Eligibility Criteria

Inclusion Criteria	Exclusion
1. Disease duration longer than 6 months	1. Age below 10 years or above 45 years
2. Age between 10 and 45 years old	2. Being pregnant or planned to be pregnant
3. Being treated with multiple daily injections or insulin pump	3. Having serious heart, liver, lung, kidney, stomach or other organs or systemic diseases requiring acute inpatient care;
4. Positive testing for at least one of the three pancreas autoantibodies: glutamic acid decarboxylase autoantibody (GADA), insulinoma-associated-2 autoantibodies (IA-2A), zinc transporter 8 autoantibody (ZnT8A)	4. Having serious chronic complications, including proliferative diabetes retinopathy, diabetes nephropathy (estimated glomerular filtration rate [eGFR]<45mL/min/1.73m^2) or diabetes foot;
5. HbA1c > 6.5%	5. Having cognitive impairment or mental illness, or any other condition or disease that may hamper from compliance with the trial
6. Owning a smartphone that can use WeChat and online conference platforms	6. Had encountered major life events related to diabetes in the past six months

Table 2 Key Contents of DSMES Video Courses

Video Courses Area	Examples that Focus on T1DM
1. Healthy eating and insulin use	Basic and advanced knowledge of food, glycemic index and glycemic load Food storage and utilization Carbohydrate counting vs intuitive dosing Impact of composition of meals (carbohydrate, fat, protein, glycemic index, glycemic load, alcohols) on glucose levels Insulin use in different foods Determine the use of insulin according to the pre-prandial blood glucose
2. Insulins, insulin injection and pumps and peers’ experience	Diabetes pathophysiology and treatment options Types of available insulins Methods of insulin delivery Preservation and carrying of insulin Basic knowledge of insulin pumps Basal and bolus insulin use of insulin pump Peers’ experience: fractional injection, waiting after insulin injection, pump use
3. Blood glucose monitoring	Self monitoring of blood glucose Continuous blood glucose monitoring How to interpret blood glucose data Reviewing insulin use according blood glucose data
4. Acute complications, blood glucose fluctuation and peers’ experience	Preventing, detecting and treating acute complications (including hypoglycemia, hyperglycemia and DKA) Causes and treatment of blood glucose fluctuation Peers’ experience sharing for hypoglycemia and hyperglycemia treatment
5. Special session for teenagers and their caregivers	Diabetes parent-child learning course: speak well and love well Adolescents’ individual characteristics, brain maturity and adult growth Mature minor rules Parent-child connection, listening, communication and empathy
6. Sick day guidelines and peers’ experience	Blood glucose change and monitoring in sick days Ketone testing Diet and insulin use
7. New technologies and peers’ experience	New technologies, smart devices and their impact on diabetes management
8. Physical activity and peers’ experience	The impact of different activities on glucose and insulin dose adjustment recommendations Peers’ experience on different forms of exercise, the change of blood glucose, the insulin use experience
9. Chronic complications of diabetes	Understanding the risk for complications of T1DM Preventing, detecting, and treating chronic complications and comorbidities of diabetes, including diabetes nephropathy and retinopathy, immune-related thyroid disease, chylous diarrhea, etc. Diet for diabetes nephropathy and retinopathy
10. Diabetes and I: peers’ experience	Campus life and parent-child interaction Diabetes distress and burnout, healthy coping with psychosocial issues and concerns, developing personal strategies to promote health and behavior changeIdentifying and accessing resources
11. Diabetes and I: peers’ experience	Marriage Genetic risk of T1DM

Abbreviations: TIDM, Type 1 Diabetes mellitus; DSMES, diabetes self-management education and support; DKA, diabetic ketoacidosis.

Figure 1 Study design and flow chart of the participant recruitment and follow-up.

Table 3 Baseline Characteristics of Study Participant

Values, Mean (SD) or n [%]	Age ≥ 18 Years	Age < 18 Years
Age, years	31.0±5.9	12.1±2.0
Sex (male), n (%)	7 (25.9)	2 (20.0)
Duration of diabetes, years	5.1 (2.4~11.2)	1.4 (0.5 ~2.0)
Duration of diabetes, months	61.0 (29.0~134.0)	16.5 (6.0 ~24.3)
Education, n (%)
Primary school		6 (60.0)
Junior high school	1 (3.7)	4 (40.0)
Senior high school	4 (14.8)
University and above	22 (81.5)
Body weight, kg	55.2±7.7	44.7±11.9
BMI, kg/m^2	20.4±2.0	18.7±3.4
Treatment, n (%)
Insulin pump	10 (37.0)	5 (50.0)
Insulin pens	17 (63.0)	5 (50.0)
CGM user, n (%)	24 (88.9)	10 (100.0)
Attended online sessions, n (%)
≥ 8 sessions	23 (85.2)	6 (60.0)
≥ 6 sessions	25 (92.6)	10 (100.0)
Attended the 1st and 2nd session	27 (100.0)	10 (100.0)
Attended the third session	27 (100.0)	9 (90.0)
Attended the fourth session	25 (92.6)	9 (90.0)

Notes: Skewed distributed variables are represented by median and interquartile range (Q1~Q3), and normally distributed variables are represented as mean ± standard deviation, and Chi-square test or Fisher’s test were used for comparison between groups.

Abbreviations: BMI, Body mass index; CGM, continuous glucose monitoring.

Table 4 Changes in HbA1c, TIR and Hypoglycemic Event in Study Population from Baseline to Follow-Up

Variables	Age ≥ 18 Years			Age < 18 Years
	Baseline	Follow Up	P value	Baseline	Follow Up	P value
HbA1c, %	6.92±0.89	6.47±0.78	0.002	7.32±1.44	6.95±0.76	0.237
HbA1c<7.0%, n (%)	17 (63.0)	20 (74.1)	0.032	4 (40.0)	5 (50.0)	0.221
TIR 3.9–10.0 mmol/L, %	74.0±13.3	80.5±14.3	0.027	82.4±12.3	84.4±4.4	0.751
TBR <3.9 mmol/L, %	6.3±3.9	5.9±5.7	0.745	4.5±1.7	5.0±4.4	0.876
TAR >10.0 mmol/L, %	19.8±13.9	13.6±14.1	0.057	13.1±10.8	10.6±6.3	0.432
Hypoglycemic event in previous 1 month, n	6.0 (3.0~11.0)	4.0 (2.0~6.0)	0.026	5.0 (2.3~10.0)	3.5 (2.0~5.8)	0.446

Notes: Skewed distributed variables are represented by median and interquartile range (Q1~Q3), and normally distributed variables are represented as mean ± standard deviation, and Chi-square test or Fisher’s test were used for comparison between groups.

Abbreviations: TIR, time in range; TBR, time below range; TAR, time above range.

Table 5 Changes in Behavior and Life Quality Score

Variables and Domains	Baseline	FOLLOW UP	P value
Age ≥ 18 years
SMOD-CA score	79.6±14.1	84.6±14.4	0.026
Daily performance	17.0±3.1	17.8±3.1	0.081
Disease management and collaboration	29.7±5.4	30.1±6.8	0.721
Coping with disease-related problems	18.2±3.8	19.9±3.4	0.020
Goals of disease management	14.7±4.9	16.8±3.9	0.000
Age < 18 years
DBRS score	0.61 ± 0.13	0.62 ± 0.10	0.840
Daily prevention behaviors	0.75 ± 0.12	0.77 ± 0.11	0.363
Modifications of diabetes care plan	0.50 ± 0.20	0.53 ± 0.20	0.724
Intervention behaviors	0.65 ± 0.19	0.66 ± 0.17	0.879
Other diabetes care practices	0.55 ± 0.23	0.52 ± 0.16	0.474

Notes: Normally distributed variables are represented as mean ± standard deviation.

Abbreviations: SMOD-CA, self-management scale for Chinese adults; DBRS, diabetic behaviour rating scale.

Table 6 The Characters Comparison Between Groups of Changes in Behavior and Life Quality Score

Variables and Domains	B-L Score ≥ 24	B-L Score < 24	P value
Age ≥ 18 years
Age, years	32.4 ± 5.9	29.3 ± 5.6	0.184
Sex (male), n (%)	4(26.7)	3(25.0)	0.922
Duration of diabetes, years	5.8(2.3~13.2)	4.7(2.6~9.9)	0.981
Insulin treatment (pen), n (%)	9(60.0)	8(66.7)	0.722
CGM user, n (%)	13(86.7)	12(100.0)	0.189
Location of residence (urban area), n (%)	11(73.3)	11(91.7)	0.223
Insurance status, n (%)			0.156
Without insurance	0(0.0)	2(16.7)
Around 50% insurance	2(13.3)	3(25.0)
Public/citizen insurance	13(86.7)	7(58.3)
HbA1c change	−0.4 ± 0.9	−0.5 ± 0.4	0.587
Hypos change	−1.0(−5.0~-1.0)	−4.5(−11.5~4.3)	0.614
Behavior score at follow up
SMOD-CA	85.7 ± 15.2	83.3 ± 13.1	0.669
Daily performance	17.9 ± 3.4	17.9 ± 2.7	0.989
Disease management and collaboration	30.8 ± 6.7	28.9 ± 6.7	0.476
Coping with disease-related problems	19.5 ± 3.6	20.6 ± 3.1	0.431
Goals of disease management	17.5 ± 4.2	15.9 ± 3.3	0.302
Behavior score improved, n (%)
SMOD-CA	7(46.7)	9(81.8)	0.069
Daily performance	6(40.0)	7(63.6)	0.234
Disease management and collaboration	4(26.7)	7(63.6)	0.059
Coping with disease-related problems	6(40.0)	9(81.8)	0.033
Goals of disease management	12(80.0)	10(90.9)	0.446
Age < 18 years
Age, years	12.6 ± 1.3	11.6 ± 2.6	0.468
Sex (male), n (%)	2(40.0)	0(0.0)	0.114
Duration of diabetes, years	2.0(0.8~5.9)	0.9(0.5~1.7)	0.222
Insulin treatment (pen), n (%)	2(40.0)	3(60.0)	0.527
CGM user, n (%)	4(80.0)	4(80.0)	1.000
Location of residence (urban area), n (%)	5(100.0)	5(100.0)
Insurance status, n (%)			0.264
Without insurance	1(20.0)	1(20.0)
Around 50% insurance	4(80.0)	2(40.0)
Public/citizen insurance	0(0.0)	2(40.0)
Father education, n (%)			0.490
Junior high school	2(40.0)	1(20.0)
Above senior high school	3(60.0)	4(80.0)
Mother education, n (%)			0.490
Junior high school	2(40.0)	1(20.0)
Above senior high school	3(60.0)	4(80.0)
Classmates know his diabetes, n (%)	2(40.0)	4(80.0)	0.197
Teachers know his diabetes, n (%)	4(80.0)	5(100.0)	0.292
HbA1c change	−0.7 ± 1.1	0.0 ± 0.7	0.219
Hypos change	0.0(−8.5~0.5)	0.0(−5.0~4.0)	0.548
Behavior score at follow up
DBRS	0.60 ± 0.12	0.64 ± 0.08	0.526
Daily prevention behaviors	0.74 ± 0.14	0.79 ± 0.08	0.487
Modifications of diabetes care plan	0.49 ± 0.23	0.57 ± 0.18	0.586
Intervention behaviors	0.63 ± 0.20	0.68 ± 0.17	0.651
Other diabetes care practices	0.53 ± 0.21	0.52 ± 0.10	0.942
Behavior score improved, n (%)
DBRS	2(40.0)	3(60.0)	0.527
Daily prevention behaviors	3(60.0)	4(80.0)	0.490
Modifications of diabetes care plan	2(40.0)	4(80.0)	0.197
Intervention behaviors	3(60.0)	2(40.0)	0.527
Other diabetes care practices	0(0.0)	3(60.0)	0.038

Notes: Skewed distributed variables are represented by median and interquartile range (Q1~Q3), and normally distributed variables are represented as mean ± standard deviation, and Chi-square test or Fisher’s test were used for comparison between groups.

Abbreviations: Hypos, Hypoglycemic event in previous 1 month; SMOD-CA, self-management scale of patients with type 1 diabetes for Chinese adults; DBRS, Chinese version of diabetic behavior rating scale in children and adolescents with type 1 diabetes.